Hierarchy is deeply embedded in the infrastructure of health systems and traditional methods of medical training — but some leaders are opting for a different approach.
A recent survey commissioned by Jackson Physician Search and Kirby Bates Associates found growing adoption of “triad” leadership models across healthcare organizations. The results were based on responses from 179 healthcare C-suite leaders. The survey found that 90% of respondents have experience with dyad or triad leadership models, and 7 in 10 view these structures as essential or strong when implemented intentionally.
“A true triad model leadership was new to me when I came to CommonSpirit, and the triad model is basically the [chief nursing officer], the [chief medical officer] and the CEO,” Kristen Mascotti, MD, CMO of Colorado Springs, Colo.-based Penrose Hospital and market CMO of Greater Colorado and Kansas for the Mountain Region of Chicago-based CommonSpirit.
“And in this organization, all three of those individuals are clinical,” she continued, noting that the structure at CommonSpirit differs from many in that there is not a COO role.
“I think the power of the triad relationship is it really does blend the clinical voice with the administrative operations to reduce silos and drive team engagement,” Dr. Mascotti said. “We focus on the outcomes in quality and patient safety, but also patient experience and efficiency. That triad, that relationship, is so key to driving team dynamics for organizational success.”
Respondents in the survey rated triad leadership as most effective in clinical areas. Clinical outcomes and patient safety and quality were rated more than 8 out of 10 in effectiveness, while achievement of defined performance goals was rated nearly 8 out of 10.
True success in this model of leadership relies on having shared goals, vision and “mutual respect,” as opposed to being a partnership in name only. In speaking about their research nationally, Dr. Mascotti and her team learned that many systems are looking to invest in these leadership structures during the hiring process and looking to identify qualities and skills that will make leaders compatible in a dyad or triad dynamic specifically.
“What we’re finding is it’s the actual relationship of the individuals that determines the success of the teams, and so some of the highest functioning organizations are doing upfront investment in different modes of evaluating dyad or triad compatibilities, even prior to hire,” she said. While few systems are out that far ahead of the research, pre-hire evaluations framed by this model are becoming best practice, she added.
The most high-functioning organizations are looking for more than just an interview fit, Dr. Mascotti said, and are actually “looking at core capabilities between the individuals and studying that amongst themselves.”
“That becomes the foundation that makes it different from a named dyad or named triad,” she said.
In looking at a dyad or triad leadership structure, it becomes more important that leaders can complement each other’s strengths and weaknesses, rather than operate in a siloed role.
“When we need to seek each other’s guidance, then we also know our synergies,” Dr. Mascotti said. “That’s where we can really create transformative change quickly.”
In her own experience, the triad or dyad model helped successfully de-escalate and resolve a highly emotional conflict between provider teams that included both nurses and physicians.
“We said, ‘We are here to understand what happened, how we can improve next time from a system standpoint, and everyone’s going to maintain professionalism.’ And it was a very difficult circumstance,” she added, noting that having support from her CNO was essential in bringing the teams together.
“The teams did de-escalate,” she said. “We did identify system issues we could do better next time.”
She attributes her dyad’s success in that situation to an honest unraveling of traditional ladders of power and leadership in health systems — which historically swayed in favor of physicians over nurses and other clinicians.
“What we hear from administration and nursing is specifically: ‘Well, we are a dyad in words, but, we really know who’s going to make the decision here,’ — meaning the physician. Or, ‘We really know who’s going to do the work here,’ meaning the administrator or nursing,” she said. “The best [dyads or triads] are when there’s flattening of the hierarchy and ego, and that means the physician. It means that as a physician, you are an equal team member.”
The model encourages skill and knowledge sharing across clinical and administrative roles, and those who will succeed in these models bring a genuine desire to learn from their team members.
“You [physicians] have plenty to learn from the administrator, from a nurse, and you have the deference and curiosity to do so,” she said. “I do think that is a place where physicians can really help encourage true partnership — what we mean by true partnership — is mutual respect.”
The survey also identified hierarchical decision-making, power dynamics, lack of psychological safety, role confusion and competing priorities as barriers to the success of dyads and triads — all of which relate to trust.
“We really dig a little bit into what trust is,” Dr. Mascotti said. “There’s two pillars of it: character and capability, and you need to have both. You can have someone you trust very much, but you just don’t think they’re highly capable or matched to the job that they’re in. Likewise, someone can be fantastic at their job, but maybe are not as team based, more singular based and or don’t have more that integrity component.”
Systems that will successfully implement this model will prioritize establishing this trust through respect and clearly communicated expectations, she added.
“The ones that work the best do it by influence,” she said. “They do it by sharing goals, because I am only successful if my CEO and CNO are successful. And if we all come from that standpoint, we can have tough conversations about how we’re going to handle this together. That’s what makes it effective.”
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